A patient assessment reveals distended neck veins, pulsus paradoxus, and decreased systolic pressure. This assessment is most consistent with:
cardiac
... [Show More] tamponade.
The nurse is caring for a patient with severe sepsis and third-degree heart block. The patient is hypotensive. The treatment for this life-threatening rhythm change includes:
transcutaneous pacing.
A patient is admitted to the ICU with suspected cervical spinal cord injury following a motor vehicle accident. The most important nursing intervention for this patient is to:
immobilize his head.
The nurse assesses a patient's chest tube drainage 2 hours following thoracic surgery. The total drainage in the system is 200 mL. The nurse knows that:
this is an excessive amount of drainage
The patient being admitted requires CRRT therapy. The nurse assigned to admit the patient has not been educated on this therapy. The charge nurse adjusts the assignment so that a nurse with 3 years experience in CRRT therapy is assigned to the patient. This type of
decision making is an example of:
the synergy model for patient care.
The patient diagnosed with acute tubular necrosis (ATN) and experiencing severe dehydration, sepsis, and pneumonia is now in the polyureic stage of ATN. The most important nursing action is to:
monitor electrolyte levels and signs of fluid depletion.
A patient has an elevated central venous pressure (CVP) measurement. The most likely reason is:
right heart failure.
Diabetes insipidus is usually treated with
vasopressin.
Which physiologic effect is produced by alpha-1 receptors?
Vasoconstriction
The patient experiencing an acute myocardial infarction (AMI) arrived on the unit an hour ago with TPA infusing. Initially, the patient's neurologic exam was normal. The nurse assesses the patient and finds him now disoriented. The next nursing action should be to:
discontinue the TPA.
A patient has cardiomyopathy and is unstable. The nurse understands that the treatment goal is to improve contractility, reduce preload and reduce afterload. The nurse anticipates that medication management will include:
dobutamine and nitroprusside infusions
A continuous drip of a medication is ordered at a rate of 2 mg/min. The standard mixture of this medication to yield a final concentration of 2 mg/mL is 1 g of the medication in 500 mL of IV fluid. At what rate in milliliters per hour should the IV pump be set?
60 mL/hr
A practitioner has ordered 700 mg of an antibiotic. The medication label states, "Add 5 mL sterile water to 1 g of this medication; 0.5 g = 2 mL." How many milliliters should be given?
2.8 mL
A practitioner order is written for a continuous infusion of insulin at 3 units/hr; the premixed solution is composed of 100 units of regular U-100 insulin in 100 mL normal saline. At which rate should the infusion run?
3 ml/hr
A dose of 35 mg of a corticosteroid is ordered to be given IM to treat inflammation. The medication is available as 250 mg/10 mL. How many milliliters should be administered?
1.4 ml
A practitioner's order prescribes levothyroxine 0.075 mg PO daily. The available medication is levothyroxine 25-mcg tablets. What will the nurse administer?
3 tabs
The actions of nitroglycerin in the management of angina include
coronary artery dilation and peripheral venous dilation.
The most common cause of right heart failure is:
left heart failure.
The nurse is differentiating between right- and left-sided heart failure in an assigned patient. For right-sided heart failure, the patient presents with edematous extremities, nausea/vomiting, and:
anorexia.
The nurse is assigned to a patient with acute adrenal insufficiency (Addisonian crisis). The practitioner orders the steroids to be discontinued quickly. The nurse knows to question the order because:
steroids should be withdrawn slowly to allow for pituitary production of ACTH
The nurse is caring for a patient who has atrial fibrillation. The patient is attempting to understand why this dysrhythmia developed in him. The nurse educates this patient about his risk factors, including:
diabetes mellitus.
The nurse is assigned a patient who is experiencing chest pain resulting from coronary artery spasms while at rest. The nurse quickly realizes that the patient is suffering from:
variant (Prinzmetal's) angina.
A blood transfusion is: indicated in cases of
active hemorrhage resulting in shock
Prior to administering digoxin to a patient, the nurse assesses the:
apical pulse for 1 minute.
The nurse has a patient who has sustained paroxysmal supraventricular tachycardia (PSVT). The medication that is most effective for treatment is:
adenosine.
A patient with a coronary artery bypass graft (CABG) has a chest tube in place. The nurse suspects an air leak, because the collection unit displays:
bubbling in the water seal chamber.
A patient has been admitted to the telemetry unit with infective endocarditis. During the nursing assessment, the nurse notes the confirmatory findings of petechiae, splinter hemorrhages, and:
Osler's nodes.
A patient reports unrelenting, crushing chest pain; nausea; and dyspnea. The nurse suspects an acute myocardial infarction. What change should the nurse expect to see on the patient's ECG?
ST-segment elevation
During an acute lateral myocardial infarction, changes will be seen in which ECG leads?
I, aVL, V5, V6
Acute pericarditis is most commonly associated with:
renal failure.
The primary sign that indicates an intraoperative stroke is:
seizures.
Rather than impeding lung blood flow, pulmonary emboli composed of _____________ injure blood vessels and cause acute respiratory distress syndrome (ARDS).
fat
The most common lethal arrhythmia in the first hour of a myocardial infarction-
v. fib
Evaluation of the comprehension of instructions given to a new nurse regarding the QT interval on an ECG strip-
Beginning of QRS to end of T-wave- less than ó of preceding R-R interval- <.4, prolongation leads to torsades
The mechanism of action for calcium channel blockers in the treatment of angina
allows blood vessels to relax and open
The primary classifications of physical traits that are manifested by patients with acute onset delirium
Restlessness, pacing, agitation, mood change, hallucination, uncooperative, reduced motor activity, sluggishness, in a daze
Cardiovascular manifestations of adrenal insufficiency-
low bp, arrhythmias, CHF
An imaging test used to confirm the presence of hypercortisolism (Cushing's disease)
MRI
The length of time that digoxin must be held prior to elective cardioversion-
24-48 hr
The single most important laboratory test in a patient who appears to be intoxicated with ethanol-
glucose
The most accurate test to use in diagnosing sleep apnea
polysomnography
Risk factors that may lead to the development of atrial fibrillation-
HTN, MI, DAD, Congenital, Thyroid, drugs, abn heart valves, SSS, Pulmonary disease, viral infection, stress, OSA
The ECG leads in which changes will be seen during an acute lateral myocardial infarction
ST segment elevation in anterior leads (V3 and V4)
The priority assessment the nurse should make prior to administering digoxin (Lanoxin®) to a patient-
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